Medication Administration Orientation and …

1 Medication Administration Orientation and observation Nurse Observed: Unit: Date: Time: Nurse Auditor: YES NO Comment 1. Medication Cart is: a. Prepared with supplies prior to pass b. Clean and organized. c. Locked when unattended. 2. Nurse washes hands prior to administering meds. 3. Medication keys are retained by nurse at all times. 4. Fluids and applesauce are covered and dated. 5. Resident is identified by wrist band. 6. Medication requiring VS are done and recorded on med sheet before pouring med. a. If AP required- hands and equipment washed before use. b. Privacy is provided. 7. Resident is positioned properly. 8. Medication Administration : a.

2 Meds are properly moved from container or blister pack. b. Liquid Medication is poured at eye level, with palm covering label. Remember to wipe top off. c. Nurse verifies Medication and strength with order as transcribed on Medication record. d. Resident is observed to ensure Medication is swallowed. e. Adequate and appropriate fluid is offered with Medication . f. Medication record is signed immediately after Administration . g. Controlled substance signed immediately after Administration . h. Were the 5 rights observed? YES NO Comment 9. Eye Medication is administered by washing hands before and after. Gloves worn if an eye infection.

3 10. Medication via gastric tubes administered per policy and procedures. a. Resident properly positioned. b. Tube checked for placement and patency. c. Tube is flushed before and after medications. 11. Injections are administered per facility policy and procedures. a. Injection sites are checked for signs of redness, swelling or lesions. b. Resident observed for adverse reaction after injection. c. Syringes and needles are disposed of in sharps container not capped. 12. Side effects of Psychoactive meds are noted (lethargy, hallucinations). * Use 14 day evaluation sheet. 13. Medication pass not interrupted. 14. Controlled drugs stored under double lock and key.

4 15. All residents rights observed. 16. Medications refused or withheld are documented properly on Medication sheet and chart. 17. Medications administered within appropriate time frame. 18. Medication errors reported to supervisor. 19. PRN Medication were they charted on correctly using medex and chart. - Was the reason indicated? - Was the response documented? 20. Were medications pre-poured? 21. Were medications left at bedside? 22. Was narcotic count done correctly? 23. Was Medication cart cleaned and locked after completion of med pass? 24. Was the nurse able to identify action and common side effects of the medications administered?

5 2. Follow-up Needed/Corrective Action Taken Nurse Observed Date Nurse Auditor Date Staff Development Date 3.